World Journal ofPsychiatry

World J Psychiatr 2019 March 27; 9(2): 30-46

ISSN 2220-3206 (online)

Published by Baishideng Publishing Group Inc

W J P World Journal ofPsychiatry

Contents Monthly Volume 9 Number 2 March 27, 2019

ORIGINAL ARTICLE

Observational Study

30 Parenting preschoolers with autism: Socioeconomic influences on wellbeing and sense of competenceMathew NE, Burton KLO, Schierbeek A, Črnčec R, Walter A, Eapen V

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2I

ContentsWorld Journal of Psychiatry

Volume 9 Number 2 March 27, 2019

ABOUT COVER Editorial Board Member of World Journal of Psychiatry, MeeraBalasubramaniam, MD, Assistant Professor, Department of Psychiatry,New York University School of Medicine, New York, NY 10016, UnitedStates

AIMS AND SCOPE World Journal of Psychiatry (World J Psychiatr, WJP, online ISSN 2220-3206,DOI: 10.5498) is a peer-reviewed open access academic journal that aims toguide clinical practice and improve diagnostic and therapeutic skills ofclinicians. WJP covers topics concerning behavior and behavior mechanisms,psychological phenomena and processes, mental disorders, behavioraldisciplines and activities, adjustment disorders, anxiety disorders, delirium,etc. Priority publication will be given to articles concerning diagnosis andtreatment of psychiatric diseases. The following aspects are covered:Clinical diagnosis, laboratory diagnosis, differential diagnosis, imagingtests, pathological diagnosis, etc. We encourage authors to submit their manuscripts to WJP. We will givepriority to manuscripts that are supported by major national andinternational foundations and those that are of great basic and clinicalsignificance.

INDEXING/ABSTRACTING The WJP is now abstracted and indexed in PubMed, PubMed Central, Emerging

Sources Citation Index (Web of Science), China National Knowledge Infrastructure

(CNKI), and Superstar Journals Database.

RESPONSIBLE EDITORSFOR THIS ISSUE

Responsible Electronic Editor: Ying-Na Bian Proofing Editorial Office Director: Jin-Lei Wang

NAME OF JOURNALWorld Journal of Psychiatry

ISSNISSN 2220-3206 (online)

LAUNCH DATEDecember 31, 2011

FREQUENCYMonthly

EDITORS-IN-CHIEFRajesh R Tampi

EDITORIAL BOARD MEMBERShttps://www.wjgnet.com/2220-3206/editorialboard.htm

EDITORIAL OFFICEJin-Lei Wang, Director

PUBLICATION DATEMarch 27, 2019

COPYRIGHT© 2019 Baishideng Publishing Group Inc

INSTRUCTIONS TO AUTHORShttps://www.wjgnet.com/bpg/gerinfo/204

GUIDELINES FOR ETHICS DOCUMENTShttps://www.wjgnet.com/bpg/GerInfo/287

GUIDELINES FOR NON-NATIVE SPEAKERS OF ENGLISHhttps://www.wjgnet.com/bpg/gerinfo/240

PUBLICATION MISCONDUCThttps://www.wjgnet.com/bpg/gerinfo/208

ARTICLE PROCESSING CHARGEhttps://www.wjgnet.com/bpg/gerinfo/242

STEPS FOR SUBMITTING MANUSCRIPTShttps://www.wjgnet.com/bpg/GerInfo/239

ONLINE SUBMISSIONhttps://www.f6publishing.com

© 2019 Baishideng Publishing Group Inc. All rights reserved. 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

E-mail: bpgoffice@wjgnet.com https://www.wjgnet.com

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2II

W J P World Journal ofPsychiatry

Submit a Manuscript: https://www.f6publishing.com World J Psychiatr 2019 March 27; 9(2): 30-46

DOI: 10.5498/wjp.v9.i2.30 ISSN 2220-3206 (online)

ORIGINAL ARTICLE

Observational Study

Parenting preschoolers with autism: Socioeconomic influences onwellbeing and sense of competence

Nisha E Mathew, Karen L O Burton, Anne Schierbeek, Rudi Črnčec, Amelia Walter, Valsamma Eapen

ORCID number: Nisha E Mathew(0000-0002-0634-730X); Karen L OBurton (0000-0001-7658-5664); AnneSchierbeek (0000-0002-8917-6840);Rudi Črnčec (0000-0002-3135-6961);Amelia Walter(0000-0003-4765-2762); ValsammaEapen (0000-0001-6296-8306).

Author contributions: Mathew NE,Burton KLO, Schierbeek A, ČrnčecR, Walter A, Eapen V contributedto this paper.

Institutional review boardstatement: The collection ofinformation for this study wasapproved by the Human ResearchEthics Committee at the Universityof New South Wales, Sydney,Australia.

Informed consent statement:Families provided informedconsent for any informationcollected as part of a broader studyof an early intervention programfor Autism Spectrum Disorders tobe discussed and publishedprovided that all informationincluded in any publication isanonymised such that they cannotbe personally identified.

Conflict-of-interest statement:None.

STROBE statement: The authorshave read the STROBE Statement-checklist of items, and themanuscript was prepared andrevised according to the STROBEStatement-checklist of items.

Open-Access: This article is anopen-access article which wasselected by an in-house editor andfully peer-reviewed by external

Nisha E Mathew, Karen L O Burton, Rudi Črnčec, Amelia Walter, Valsamma Eapen, School ofPsychiatry, University of New South Wales, Sydney NSW 2052, Australia

Anne Schierbeek, Vrije Universiteit Amsterdam, De Boelelaan, Amsterdam 1081 HV, TheNetherlands

Amelia Walter, Valsamma Eapen, Academic Unit of Child Psychiatry South West Sydney andIngham Institute, South West Sydney Local Health District, Liverpool Hospital, ICAMHS,Mental Health Centre (Level L1), Locked Bag 7103, Liverpool NSW 1871, Australia

Corresponding author: Valsamma Eapen, PhD, Professor, MBBS, FRCPsych, Academic Unitof Child Psychiatry South West Sydney and Ingham Institute, South West Sydney LocalHealth District, Liverpool Hospital, ICAMHS, Mental Health Centre (Level L1), Locked Bag7103, Elizabeth Street, Liverpool NSW 2170, Australia. v.eapen@unsw.edu.auTelephone: +61-2-96164205Fax: +61-2-96012773

AbstractBACKGROUNDPrevious research suggests that parents raising a child with autism experiencehigher levels of psychological distress than parents of typically developingchildren and parents of children with other developmental disorders. Little isknown, however, about the intersection between the effects of socioeconomicstatus (SES) on the wellbeing and sense of parental competency of parents of pre-schoolers with autism and how it relates to child symptom severity.

AIMTo examine the relationship between their child’s symptom severity, SES, asmeasured by neighbourhood advantage and occupational status, on thepsychological wellbeing and perceived parenting competence among parents ofpreschoolers with autism.

METHODSParents of 117 preschool-aged children with a diagnosis of autism spectrumdisorder (ASD), 107 mothers and 54 fathers, completed questionnaires about theirchild’s symptoms of ASD and functioning, their own perceptions of theirwellbeing and parental competence on entry to an early intervention program inSydney, Australia. Parents also provided demographic information pertaining totheir occupation, level of education attained and address (postcode). All childrenwere also assessed for their severity of symptoms using the Autism DiagnosticObservation Schedule. The Australian Socioeconomic Index of occupational

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 230

reviewers. It is distributed inaccordance with the CreativeCommons Attribution NonCommercial (CC BY-NC 4.0)license, which permits others todistribute, remix, adapt, buildupon this work non-commercially,and license their derivative workson different terms, provided theoriginal work is properly cited andthe use is non-commercial. See:http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Invitedmanuscript

Received: May 29, 2018Peer-review started: May 29, 2018First decision: July 9, 2018Revised: February 5, 2019Accepted: February 18, 2019Article in press: February 19, 2019Published online: March 27, 2019

status as a measure of familial SES and the Index of Relative Socio-economicAdvantage and Disadvantage as a measure of neighbourhood advantage wereused to examine the impact of SES on parental sense of competence andwellbeing.

RESULTSCompared to normative populations, both mothers and fathers in our samplereported significantly higher levels of parenting sense of efficacy but lower levelsof interest in the parenting role. Mothers also displayed higher levels ofsatisfaction. Both mothers and fathers displayed higher levels of depression thannormative populations with mothers also reporting greater levels of stress andanxiety. Child symptom severity was associated with maternal parentingcompetency with these relationships amplified among mothers with higherfamilial SES and who lived in areas of greater neighbourhood advantage.Increased adaptive functioning was associated with better maternal wellbeing,particularly among mothers who lived in areas of greater neighbourhoodadvantage. Contrastingly, paternal parenting competence was generally notinfluenced by child adaptive functioning or symptom severity, although for thosein higher familial SES brackets, children’s symptom severity and maladaptivesymptoms were negatively related to paternal sense of parenting efficacy. Therewas a trend towards moderate relationships between lower familial SES andgreater depression, stress and anxiety among fathers, but no relationship withtheir child’s ASD symptom severity or functioning.

CONCLUSIONSES differentially impacts wellbeing and sense of parenting competence and itsrelationship to the impact of child symptoms for mothers and fathers ofpreschoolers with autism.

Key words: Wellbeing; Parenting competency; Autism; Autism spectrum disorder; Parent;Mother; Father; Socioeconomic status

©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.

Core tip: Previous research suggests that parents raising a child with autism experiencecomparatively higher levels of psychological distress than other parents. Little is known,however, about how socioeconomic status (SES) affects perceived parenting competenceand overall wellbeing and how these factors relate to the nature of children’s autism. Inthis study, a cross-sectional analysis of parents of preschoolers with autism found thatmothers and fathers were differentially affected by SES and their children’s symptomseverity. Those working with parents of pre-schoolers with autism need to considerdifferential effects of factors, such as SES and symptom severity, in contributing tomaternal and paternal wellbeing and their experiences of parenting.

Citation: Mathew NE, Burton KLO, Schierbeek A, Črnčec R, Walter A, Eapen V. Parentingpreschoolers with autism: Socioeconomic influences on wellbeing and sense of competence.World J Psychiatr 2019; 9(2): 30-46URL: https://www.wjgnet.com/2220-3206/full/v9/i2/30.htmDOI: https://dx.doi.org/10.5498/wjp.v9.i2.30

INTRODUCTIONAutism spectrum disorder (ASD) is a life-long neurodevelopmental disordercharacterised by deficits in communication and social interaction, and restricted,repetitive patterns of behaviour, activities or interests[1]. The prevalence of ASDappears to be rising worldwide[2] with autism currently estimated to affect around onein every 59 children aged 8 years old[3]. Parenting children with autism can bephysically, psychologically, socially and financially demanding[4,5].

Parents of children with autism face multiple challenges such as difficultiesassociated with the diagnostic process, finding appropriate intervention and

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

31

educational programs, managing symptoms and behaviour on a daily basis, stressorsfurther compounded by the financial burden due to the high cost of services[6-8].Consequently parents of children with autism have been reported to show clinicallyelevated stress levels, poorer mental and physical health and lower quality of lifeacross a range of studies[9-12]. A meta-analysis of 16 studies found higher levels ofpsychological distress among parents of children with autism relative to parents ofchildren with other neurodevelopmental disabilities and medical conditions[10]. Inaddition to the impact on parental wellbeing, high levels of parenting stress have beenfound to reduce the effectiveness of a range of early interventions[13] and increase theuse of ineffective parenting strategies that contribute to a decrease in the child’sexecutive functioning and an increase in behavioural regulation problems[14].

Parenting sense of competence is a construct that has emerged as having asignificant impact on parental wellbeing among parents of children with autism.Greater scores on dimensions of parenting competence including parents’ satisfactionwith the role of parents and perceived self-efficacy is associated with improvedparental wellbeing[12,15,16]. The limited research to date suggests no difference inperceived satisfaction with the parenting role and a third dimension, interest andengagement with the parenting role, but increased sense of parenting efficacy in asmall sample of mothers of children with autism compared with the normative dataof Rogers and Matthews[17,18].

The effect of the severity of a child’s overall autism symptoms on parentalwellbeing is however not clear. While some studies have found it to be a significantcontributor to lower parental wellbeing[19,20], other studies have found limitedevidence for a link between parental wellbeing and symptom severity[21-23]. The onestudy examining the relationship between ASD severity and parenting sense ofcompetency suggested that there is lower sense of satisfaction with the parenting rolewith increased symptom severity of ASD[15]. Some research has attributed the highlevel of psychological distress among parents of children with autism to the core traitsof social communication deficits[10,24] and restrictive, repetitive behaviours[24-26] in theirchildren. These hallmark deficits often make it difficult for parents to form secure,reciprocal relationships with their children[27,28]. Expressive communication difficultiesmay also contribute to the high levels of maladaptive, destructive and self-injuriousbehaviours found among children with autism[29-32]. The severity of a child’smaladaptive behaviours, negative behaviours directed towards the self (termedinternalising behaviours) and towards others (externalising behaviours), have alsobeen found to be a significant contributor to the wellbeing of mothers of children withautism[33-36]. However, research has not yet been conducted into the impact ofchildren’s adaptive and maladaptive functioning on parental sense of competency[15].

Recent analyses suggest that environmental factors, including socioeconomic status(SES) may have a greater impact on parent stress than child-related factors[37]. Keymeasures of SES include family measures including household income and parentallevel of education, and measures of community SES including community resources.The inadequate resources available to those from lower SES background have beenproposed to exacerbate parenting stress and decrease wellbeing[38]. Additionally,internalising disorders such as depression and anxiety have been found to be directlyassociated with lower SES within the general population, findings which have beentheorised to be a product of the everyday stressors associated with poverty[39]. Livingin deprived neighbourhoods is also linked to poorer mental health independent ofpersonal SES[40]. A number of studies have found evidence to suggest that having achild with autism or other disability is associated with reductions in householdincome, and thus lower SES[41,42]. However, the impact of SES on wellbeing in parentsof children with autism is unclear. Among parents with children with autism, whilehigher family income has been associated with increased maternal wellbeing and self-reported quality of life[37,43,44], greater levels of stress among parents of children withautism and other disabilities have been related to higher levels of education[45-47].Conversely, other research suggests that higher levels of education but not incomeimprove paternal quality of life in those with children with autism[48]. One study thatexamined the impact of income of parenting competence found that mothers withgreater incomes had increased parenting satisfaction but had lower efficacy relative tomothers with lower incomes[15]. Families with low SES encounter a greater number ofstructural barriers which impair their capacity to meet their children’s needs[49] whichin turn may have an adverse impact on parental wellbeing.

With the potential relationship between symptoms of ASD and parental wellbeing,it is important to also consider how SES relates to ASD symptomatology andfunctioning in children with ASD. The little research that has been conductedsuggests an increase in mood and behaviour problems among children with autismfrom low SES families[50,51], and that living in impoverished neighbourhoods isassociated with greater comorbid intellectual disability among children diagnosed

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

32

with autism[52,53]. Further, differential access to diagnostic services based on the SESmay also contribute to delayed diagnosis within more deprived neighbourhoods,consequently delaying intervention and increasing the severity of a child’s ASDsymptoms[42,53-57].

The literature relating to the relationship between SES and symptoms of ASD iscomplicated by the inclusion of a high proportion of participants living below thepoverty line[48,58], the use of author-generated measures of economic support[37] and thecountry in which the research was conducted with different patterns of findingsemerging in countries with universal healthcare compared to American studies. Thevariation in the use of measurements of SES further complicates the conclusions thatcan be drawn. Further research is therefore required to understand the role of SESusing validated measures in the Australian setting.

This study aimed to clarify the relationship between child related factors relating toASD symptom severity and adaptive and maladaptive behaviours, and parentalpsychological wellbeing and whether this relationship is moderated by measures ofSES. Additionally, we sought to explore whether there are differences between fathersand mothers in terms of these factors. We hypothesised that there would besignificantly greater levels of symptoms of depression, anxiety and stress in parents ofchildren with autism as compared to general population. We also hypothesised thatthere would be an association between greater autism symptom severity andmaladaptive behaviours and lower parental psychological wellbeing and sense ofparental competence and that this relationship would be moderated by measures ofSES.

MATERIALS AND METHODS

ParticipantsParents of children who started attending an Autism Specific Early Learning and CareCentre (ASELCC) in outer metropolitan Sydney, Australia between July 2010 andJanuary 2015, were invited to participate in the study. The centre is one of sixASELCCs established by the Australian Government providing long day child carefor children aged two to six years with a diagnosis of ASD. The centre is staffed by amultidisciplinary team including Child Care Workers, Early Childhood Teachers,Speech Pathologists, Occupational Therapists, and a Family Counsellor. Childrenenrolled in the program received individual and group-based early intervention usingthe Early Start Denver Model, an evidence-based intensive behavioural interventionfor preschool children with ASD[59-61].

All children received a diagnosis of autistic disorder or pervasive developmentaldisorder by a community-based physician using the Diagnostic and Statistical Manualof Mental Disorders fourth edition (DSM-IV), which are encompassed under thediagnosis of ASD under the DSM-5[1]. Exclusion criteria included conditions with aknown genetic aetiology (e.g., Fragile X Syndrome) or neurological (e.g., epilepsy)disorders, and significant vision, hearing, motor or physical problems. Additionalcriteria for entry to the Centre included the ability to meet fee payment throughpersonal and funding bodies including government funding, and for children to beable to physically attend the Centre.

Procedure and measuresThis study was approved by the local institutional Human Research EthicsCommittee. After providing informed consent to participate at the time of their child’senrolment in the ASELCC, parents completed a demographic questionnaire as well asstandardised questionnaires assessing parental psychological wellbeing and theseverity of their child’s autism symptoms. An objective assessment of the child’sseverity of symptoms of autism was also undertaken by researchers at the Centre. Allassessment tools used in this study have strong psychometric properties.

Parental wellbeingParental wellbeing was assessed using the Parenting Sense of Competence Scale(PSOC)[62] and the Depression Anxiety Stress Scales (DASS)[63].

The PSOC includes 17 items designed to measure parental self-efficacy, andgenerates scores on three subscales: Satisfaction, Interest and Efficacy. The PSOC wasscored such that higher scores indicated higher levels of self-perceived competency.This involved reverse scoring the Efficacy subscale, on which higher scores indicatelower levels of efficacy. The PSOC has strong psychometric properties includingsatisfactory internal consistency, rest-retest reliability, convergent validity withmeasures of child behaviour and high levels of temporal stability[17].

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

33

The DASS is a 21-item self-report measure that assesses negative affect, generatingseparate scores for the subscales of Depression, Anxiety and Stress. Higher scoresindicate greater symptomatology. The DASS-21 has excellent psychometric propertieswith high levels of internal consistency across the Depression, Anxiety and Stresssubscales as well as high levels of temporal validity, higher levels of convergentvalidity than other anxiety and depression scales[63-65].

Autism severityThe severity of the child’s autism symptoms was measured using the SocialCommunication Questionnaire (SCQ)[66] and the Autism Diagnostic ObservationSchedule (ADOS)[67] or the ADOS second edition[68].

The SCQ is a 40-item, parent-report measure of autism-specific symptoms, withhigher scores indicating increased autism severity. The SCQ produces a total score,with a score of 15 or greater considered being indicative of autism. The SCQ has threesubscales assessing problems in the domain of communication (SCQ Communicationsubscale), problems in reciprocal social interaction (SCQ Social subscale) and thepresence of restricted, repetitive and stereotyped behaviours (SCQ RRSB subscale). Agreater score on each subscale indicates a greater level of difficulty. The SCQ hasrobust psychometric properties including levels of interenal consistency, test-retestreliability and good discriminative validity between preschoolers with autism andnon-clinical samples[69-71].

The ADOS and ADOS-2 are semi-structured, standardised play-based assessmentsto examine key symptoms of autism including communication, social interaction, playand creativity, and other behaviours including restricted and repetitivebehaviours[67,68]. The assessment was conducted by researchers trained in theadministration and scoring of the ADOS. The ADOS has a cutoff score above whichautism is considered and it also provides scores indicating the likely level of severityof autism spectrum symptoms. The ADOS and ADOS-2 have sound psychometricproperties, including high levels of internal consistency, interrater reliability, test-retest reliability and diagnostic predictive validity[67,68]

Children’s adaptive functioning was assessed using the Vineland AdaptiveBehaviour Scales, Second Edition (VABS-II)[72]. The VABS-II assesses parents’perceptions of their child’s everyday adaptive functioning across broad domainsincluding communication, daily living skills, socialisation and motor skills. A norm-referenced standardised Adaptive Behaviour Composite is calculated, with higherscores indicating greater levels of adaptive functioning. The maladaptive behaviourdomain assesses problem behaviours, with higher scores indicating greaterdifficulties. The VABS-II has well-established strong psychometric properties in thepreschool age group, including high levels of internal consistency, test-retestreliability, interrater reliability and has been found to be a valid measure of theseverity of autism symptomology[72].

Socio-economic statusSES is used in this paper to describe the position of a person within a hierarchicalsocial structure[73]. Two mechanisms were used to assess SES; the first was based onparents’ occupation and education levels using the Australian Socioeconomic Index ofoccupational status (AUSEI06)[74]. The AUSEI06 is a socio-economic index developedin response to the introduction of the Australian and New Zealand StandardClassification of Occupations (ANZSCO) by the Australian Bureau of Statistics[75]. TheAUSEI06 is used to convert ANZSCO codes into occupational status scores rangingfrom 0 to 100, with higher scores indicative of higher SES. Where both parents areemployed, the AUSEI06 is calculated by taking the score of the parent with thehighest occupational status. When an individual is not in paid employment, the scoreis assigned using his or her educational level. Where two parents indicatedemployment - the highest AUSEI06 code was used; where one parent indicatedemployment, their AUSEI06 code was used; where neither parent was employed, thehighest imputed AUSEI06 code was used. The AUSEI06 is based on the InternationalSocioeconomic Index[76] in which occupation is described as the “engine” that convertseducation into income. The AUSEI06 possesses adequate psychometric properties[75].

The second mechanism of assessing SES was the Index of Relative Socio-economicAdvantage and Disadvantage (IRSAD) from the Socio-economic Indexes for Areas(SEIFA) 2016 based on the 2016 Census of Population and Housing[77,78]. The definitionof relative advantage and disadvantage refers to “people’s access to material andsocial resources, and their ability to participate in society”[79], with the IRSADproviding a summary measure[77,78]. Percentile ranking of postcodes from acrossAustralia can be used to ascertain the SEIFA score. Lower scores indicate relativelygreater disadvantage and general lack of advantage, while higher scores indicategenerally greater advantage and a relative lack of disadvantage[78].

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

34

Statistical analysisStatistical analyses were conducted using SPSS version 25.0. T-tests were used tocompare participants’ scores on the PSOC and DASS to Australian normative datapresented by Rogers and Matthews[17] for the PSOC and Crawford et al[78] for theDASS. Pearson’s r correlations were conducted to examine relationships between SES,parental wellbeing and severity of autism symptoms, with hierarchical multipleregression then used to explore possible moderating effects of SES. Correlations wereconsidered as statistically significant for P ≤ 0.01 to partially control for multiplecomparisons, however relationships to P ≤ 0.03 are reported to examine trends.Cohen’s categorisation of correlation coefficients was used in this study with ≥ 0.1denoting a small effect size, ≥ 0.3 a medium effect size and ≥ 0.5 a large effect size[80].

RESULTSOf the 165 children enrolled at the Centre in the study period, data for at least oneparent for the PSOC and/or the DASS and at least one measure of socio-economicbackground was available for 117 children. For the PSOC, data was available for 107mothers and 54 fathers; for the DASS, data was available for all subscales for 101mothers and 53 fathers. Demographic information is presented in Table 1. Themajority of children were male, with a mean age of 4.1 years at the time of enrolment.More than half were from a culturally and linguistically diverse (CALD) background,and close to half had English as an additional language spoken at home. The mostcommon languages spoken at home were Vietnamese (n = 20, 18% of sample) andArabic (n = 11, 9.9% of sample). Mothers were the predominant primary carer. Interms of SES, the majority of families lived in postcode areas in the bottom andmiddle thirds of IRSAD. However, when considering the AUSEI06 rankings, themajority of the sample fell in the top third.

Means and standard deviations for measures of ASD symptom severity arereported in Table 2. Means and standard deviations for measures of PSOC and DASSare presented in Table 3, with Table 4 providing results comparing our data with theAustralian normative data presented by Rogers and Matthews[17] for the PSOC andCrawford et al[78] for the DASS.

There were no statistically significant differences on any of the three subscales ofthe PSOC between mothers and fathers in our sample. When compared with theAustralian normative data presented by Rogers and Matthews[17], mothers in oursample had significantly higher levels of parenting sense of efficacy, but lower levelsof interest in the parenting role and comparable levels of satisfaction. For fathers inour sample, there were no differences in levels of parenting satisfaction comparedwith the normative data. However, they had significantly higher levels of parentingefficacy and lower levels of interest in the parenting role than the normative data.

There were also no statistically significant differences in levels of symptoms ofdepression, anxiety or stress as measured by the DASS between mothers and fathersin our sample. However, mothers in our sample had significantly greater levels ofsymptoms of depression, anxiety and stress than the Australian normative datapresented by Crawford et al[78]. Fathers in our sample on the also had significantlygreater levels of symptoms of depression than the normative data. However, therewere no differences in the levels of symptoms of anxiety or stress between fathers inour sample compared with normative data.

There were no statistically significant differences between scores of parentalwellbeing and levels of symptoms of depression, anxiety or stress as measured by theDASS among CALD and non-CALD mothers and fathers. There was also nostatistically significant difference in the levels of parenting satisfaction as measured bythe PSOC between CALD and non-CALD mothers and fathers.

There were no statistically significant correlations between measures of SES andmeasures of ASD symptom severity. There was a small but significant positivecorrelation between SES, measured through the IRSAD and mothers’ interest inparenting scores (Table 5). No other correlations between measures of SES andparenting sense of competence or wellbeing met significance.

There were small but significant negative correlations between children’scommunication skills and mother’s parenting satisfaction and small to moderatenegative correlations between mothers’ sense of parenting efficacy and children’scommunication skills and restrictive, repetitive and stereotyped behaviours (Table 5).There was also a trend towards a small negative correlation between children’s socialinteraction skills and maternal parenting satisfaction, and a trend towards a smallpositive correlation between children’s adaptive functioning and maternalsatisfaction.

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

35

Table 1 Demographic information

Demographic information n (%)

Sex of child (male: female, n = 117) 96 (82.1): 21 (17.9)

Age of child in years at enrolment at Centre (n = 117)

mean (SD) 4.13 (0.53)

Median (range) 4.15 (2.74-5.79)

Country of birth of child (Australia: overseas, n = 110) 106 (96.4): 4 (3.6)

Indigenous background (n = 88) 4 (4.5)

CALD background (n = 107) 63 (58.9)

English as additional language (n = 111) 49 (44.1)

Primary carer (n = 75)

Mother 68 (90.7)

Father 5 (6.7)

Other extended family 2 (2.7)

IRSAD percentile ranking (n = 116)

mean (SD) 38.8 (25.06)

Median (range) 34 (4-95)

IRSAD categories (n = 111)

Lowest third 43 (38.7)

Middle third 49 (44.1)

Top third 19 (17.1)

AUSEI06 percentile ranking (n = 112)

mean (SD) 65.56 (20.56)

Median (range) 71.6 (7.9-100)

AUSEI06 (n = 109)

Lowest third 7 (6.4)

Middle third 33 (30.3)

Top third 69 (63.3)

CALD: Culturally and linguistically diverse; IRSAD: Index of Relative Socio-economic Advantage andDisadvantage; AUESI06: Australian Socioeconomic Index 2006.

No correlations between fathers’ parenting sense of competence and severity ofchildren’s ASD symptoms met significance. There were also no significantcorrelations between mothers’ or fathers’ sense of wellbeing as measured through theDASS and severity of ASD symptoms.

There were significant correlations between mothers’ DASS and PSOC scores,fathers’ DASS and PSOC scores and the PSOC and DASS scores of mothers andfathers (results not reported; contact authors for results) (Table 6).

When correlations were conducted splitting the groups into three levels of SES (low- 0-33.3 percentiles, medium - 33.4-66.6 percentiles and high - 66.7 to 100 percentilesfor the AUSEI06 and IRSAD separately), there were significant correlations betweenparenting sense of competence and wellbeing for different levels of SES, particularlyfor those in the higher SES brackets (Table 5). No results are presented for fathers inthe middle SES tertile when using the AUSEI06 as the sample size was less than 10. Itis noteworthy that there were no significant correlations for mothers or fathersbetween symptoms of stress measured through the DASS against child’s ASDsymptom severity when the sample was split into the three SES groupings.

Moderation analyses revealed no significant interaction between SES (AUSEI06 orIRSAD) and ASD symptom severity as measured by VABS adaptive and maladaptivefunctioning scores, SCQ scores or ADOS comparison scores for any parent measuresof parenting sense of competence or wellbeing.

DISCUSSIONThis study sought to assess the extent to which SES moderates the impact of child-specific factors on the psychological wellbeing and sense of parenting competency inmothers and fathers of preschoolers with autism. We found that, while there was no

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

36

Table 2 Means and standard deviations for measures of autism spectrum disorder symptomseverity

ASD symptom severity measure mean (SD, range)

SCQ communication (n = 109) 5.66 (2.09, 0-12)

SCQ social (n = 110) 7.19 (3.47, 0-14)

SCQ RRSB (n = 110) 4.36 (2.32, 0-8)

SCQ total (n = 110) 18.36 (6.29, 2-36)

VABS adaptive (n = 99) 64.56 (12.48, 42-106)

VABS maladaptive (n = 106) 19.26 (1.87, 15-24)

ADOS severity score (n = 99) 7.11 (1.76, 1-10)

SCQ: Social Communication Questionnaire; RRSB: Restricted, repetitive and stereotyped patterns ofbehaviour; VABS: Vineland Adaptive Behavior Scales; ADOS: Autism Diagnostic Observation Schedule;ASD: Autism spectrum disorder.

effect of SES on levels of parental wellbeing or parenting competence and efficacyoverall, distinct factors impacted the wellbeing of mothers and fathers.

While there has been significant research examining the wellbeing of parents ofchildren with autism, the majority of this research has been primarily focused on theexperiences of mothers[80]. While there was no statistically significant relationshipbetween SES and paternal wellbeing or competence across our whole sample, therewas a moderate trend towards lower levels of family SES being associated withincreased levels of stress and anxiety among fathers. This trend is broadly consistentwith previous qualitative research that has highlighted fathers of children with autismoften take up the role of “breadwinner”[81], consequently lower personal SES may havea greater impact on fathers. Our findinng of a trend in this direction rather than asignifciant finding may reflect the limited sensitivity of the AUSEI06, which estimatesSES based on parental occupation or education levels, as an accurate estimate ofpersonal SES. Our findings do however contrast the results of much of the existingliterature which has not found an influence of SES on parental wellbeing[25,82,83] or hasfound that higher personal SES was associated with increased wellbeing amongmothers but not fathers[58]. These different findings may be due to differences in theconceptualisation of SES and the homogeneous demographic characteristics of theprevious studies. These studies used measures such as household income[58] orcomposite estimates of SES that incorporated personal disadvantage, occupationalstatus and income[25] or educational status and overall income[82]. The disparity in thesefindings suggest that further research is needed with more sensitve tools and morespecific categorisations of SES to better understand the impact of SES on fathers andmothers of preschoolers with autism.

Importantly, our study revealed further differences in the effect of child-specificfactors on the parenting competence and wellbeing of mothers and fathers wasaffected by both gender and SES. In this regard, parent reports of child ASD symptomseverity and adaptive functioning were associated with lower satisfaction and efficacyamong mothers but not among fathers. When the relationship between SES andparental efficacy and satisfaction was examined separately across the three SESbrackets, this relationship was only found among mothers in the highest family andhighest and middle community SES brackets. Among fathers in the highest familySES bracket from advantaged backgrounds, greater levels of maladaptive behaviourand greater symptom severity in children were associated with a lower sense ofparenting efficacy.

The finding that low paternal parenting efficacy is associated with greater childmaladaptive behaviours is consistent with the findings of earlier studies that havefound a similar relationship among fathers of typically developing children[63,83].However, it is unclear why our finding was specific to fathers from higher SESbrackets only. One possible explanation is that parents with a higher SES have higherexpectations of their children compared to parents with a lower status [84].Alternatively, parents in higher SES brackets who are working may have less time tospend with their children and address their behavioural needs. This novel findingwarrants replication with a larger sample of fathers to clarify whether differencesexist between the effect of community SES and personal SES on paternal wellbeingand to explore the underpinnings of such a differential relationship.

There was also a trend towards maternal depression and lower levels of adaptiveskills that was found to be significant among mothers from the highest community

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

37

Table 3 Means and standard deviations for mothers’ and fathers’ parenting sense ofcompetence and symptoms of depression, anxiety and stress

Mothers, mean (SD, range) Fathers, mean (SD, range)

PSOC satisfaction 3.67 (1.04, 1-6), n = 107 3.74 (0.91, 2.17-5.67), n = 54

PSOC efficacy 4.34 (0.89, 1.43-6), n = 107 4.31 (0.67, 2.71-5.71), n = 54

PSOC interest 4.88 (1.12, 1-6), n = 107 4.66 (1.00, 2.50-6), n = 54

DASS depression 3.57 (3.68, 0-13), n = 102 3.78 (4.32, 0-16), n = 54

DASS anxiety 2.76 (3.03, 0-11), n = 101 2.45 (3.01, 0-13), n = 53

DASS stress 5.32 (3.92, 0-15), n = 101 5.04 (4.42, 0-15), n = 53

PSOC: Parenting Sense of Competence; DASS: Depression Anxiety Stress Scale.

SES bracket. However other relationships emerged between child-related factors andpaternal wellbeing. Overall our results suggest that symptom severity may have agreater impact on the wellbeing, efficacy and competence of higher SES parents andcontradicts the findings of earlier studies that symptom severity and adaptivefunctioning affects maternal distress but not paternal distress[20-22]. Notably theexperiences of parents of children with autism from different SES brackets have notbeen examined separately as such these findings contribute to a more nuancedunderstanding of the influence of SES on parental wellbeing and efficacy. Furtherinvestigation is however needed to untangle the differential effects between fathersversus mothers and those from high versus low SES (personal SES) and those fromdeprived versus advantaged backgrounds (community SES).

Interestingly the differences between mothers and fathers in parenting competenceand wellbeing in our sample emerged only in the analysis of parental reports of theirchild’s ASD symptom severity using SCQ but no differences emerged in the analysisof severity as measured by the gold standard ADOS assessments. As a parent reportmeasure, the SCQ score may better reflect parental awareness and perception ofsymptoms and their severity as opposed to the objective measure of the ADOS.

Consistent with our hypothesis, we found significantly greater levels of symptomsof depression, anxiety and stress among mothers of children with autism compared tothe normative Australian data, and higher levels of symptoms of depression infathers. Our findings of elevated symptoms of depression, anxiety and stress levels inmothers with children with ASD is consistent with previous research[4,10,85,86]. We alsofound that fathers experienced significantly more symptoms of depression butcomparable levels of anxiety and stress levels to the normative sample. This is also inkeeping with the existing data where mothers have been found to have lowerwellbeing scores and higher stress scores compared to fathers of children withautism[37,87-89]. It is possible that the primary responsibility for caring for a child withautism has traditionally rested with mothers and the adverse psychological impactobserved in mothers may be a function of this primary carer responsibility rather thanthe gender of the parent[21]. While in our sample the primary caregiver role was alsopredominantly served by the mothers, the intervention program delivered throughthe Centre encourages the involvement of both parents. This in turn may haveresulted in fathers in our sample also being closely involved in parenting and earlyintervention services and therefore experiencing similar levels of depression, anxietyand stress as the mothers. While previous studies found that the depressivesymptoms reported by fathers of children with autism were comparable to thosereported by fathers of typically developing children[88], these studies have includedparents of school aged children and adolescents who may have different parentingdemands. Our study suggests that both mothers and fathers of preschoolers withautism may be at risk of heightened psychological distress.

Both mothers and fathers in our sample displayed greater parental efficacy butlower interest in the parenting role compared with normative samples[17], withmothers also displaying greater satisfaction with their parenting. This extends thefindings of previous research carried out at the same early intervention centre[18] in alarger sample and provides information on not only mothers but also fathers. Whileother studies have found lower parenting efficacy among mothers of children withautism[12,90], our finding of increased parental self-efficacy may be due to the parentalinvolvement and participation in the early intervention program for ASD that isprovided at the Centre where the study was conducted. Similar finding of betterparenting efficacy has been found following behavioural interventions for ADHD[91,92].Further research using community-based recruitment methods are necessary tounderstand the nature and interaction of the relationship between parenting

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

38

Table 4 Comparison of our data with normative data

Mothers Fathers

PSOC satisfaction1 t(864) = 2.160, P = 0.031a t(351) = -1.572, P = 0.117

PSOC efficacy1 t(864) = 13.065, P < 0.001d t(351) = 3.788, P < 0.001d

PSOC interest1 t(125.573) = -2.036, P = 0.044a t(61.599) = -2.972, P = 0.004b

DASS depression2 t(597) = 2.399, P = 0.017a t(549) = 2.158, P = 0.031a

DASS anxiety2 t(596) = 3.318, P = 0.001b t(548) = 1.760, P = 0.079

DASS stress2 t(596) = 2.090, P = 0.004b t(548) = 1.703, P = 0.089

aP < 0.05.bP < 0.01.dP < 0.001.1Compared with normative data presented in Rogers and Matthews[17].2Compared with normative data presented in Crawford et al[78].PSOC: Parenting Sense of Competence; DASS: Depression Anxiety Stress Scale.

preschoolers with autism and parenting efficacy vis-a-vis participation in earlyintervention programs. The limited associations between child ASD symptomseverity, child adaptive and maladaptive behaviours and SES on parental wellbeingand parenting sense of competence suggests that other factors may play an importantrole. The large relationship between scores on the Parenting Sense of Competency andDepression, Anxiety and Stress Scale in supplementary analyses suggests aninterrelationship between these facets, consistent with the previous literature[12,15,16],however the directionality of this relationship needs further exploration. Further, thelarge relationship between mothers’ and fathers’ wellbeing and sense of competencysuggests the interdependence of parenting competence and wellbeing within a family.These relationships also provide insight into the lack of differences in wellbeing andparenting competence between mothers and fathers. Our finding of no relationshipbetween SES and ASD symptomology is contrary to our hypothesis and deservesfurther exploration. Given the suggestion that autism in the absence of intellectualdisability may be diagnosed later among lower SES families[53,91-93], and the lownumbers of families from the lowest AUSEI06 categories who participated in thisstudy, it is possible that our study may not have fully captured the impact of SES onASD severity.

The current study has the advantage of exploring both maternal and paternalwellbeing and sense of competence in parents of preschoolers with autism whereasmuch of the previous literature has not included fathers of children with autism.Additionally this study had a high proportion of children from CALD backgroundsand it is of interest that there were no significant differences between the wellbeingand competence of parents from CALD and non CALD backgrounds in our study.However, our study examines this only in those attending an Autism Specific EarlyLearning and Care Centre (ASELCC) in one specific location in Australia. Whetherthese findings extend to parents of preschoolers attending other ASELCCs throughoutAustralia, attending other childcare or preschool settings or not attending any out ofhome day care needs to be verified through further research.

Our study also had a limited number of families in the lowest family SES categorybased on AUSEI06, with a particularly restricted limited number of fathers in thelower SES categories. Since it has been suggested that lower SES families mayexperience delays in diagnosis due to differential access to diagnostic services[53,91-93], itis possible that lower SES families have not had the benefit of early identification andenrolment to early intervention such as the centre from where this study wasconducted. Alternatively, it is possible that lower income families were less likely toparticipate in research due to time constraints.

As with much of the existing literature, the recruitment from a centre whichprovides specialised services for children with ASD may have resulted in samplingbias, as the parents of these children are already showing parenting interest andefficacy by virtue of the fact that they have sought early intervention support. It ispossible that the relationship between the factors we assessed may differ amongfamilies with limited access to early intervention, health or social services programs.Future studies which recruit from the community settings may overcome theselimitations.

Another potential reason for the limited number of parents categorised to be in thelow family SES group in this study may be due to inflation of AUSEI06 scores forfamilies with no parent reported to be working. In such circumstances, the AUSEI06

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

39

Table 5 Means and standard deviations for culturally and linguistically diverse and non-culturally and linguistically diverse parents’ parenting sense of competence and symptoms ofdepression, anxiety and stress

CALD, mean (SD, range) Non-CALD, mean (SD, range)

Mothers

PSOC satisfaction 3.65 (1.06, 1.2-5.6), n = 57 3.78 (0.98, 2-6), n = 41

PSOC efficacy 4.32 (0.84, 1.86-6), n = 57 4.34 (0.99, 1.43-5.71), n = 41

PSOC interest 4.76 (1.3, 1-6), n = 57 5.01 (0.90, 3-6), n = 41

DASS depression 3.39 (3.56, 0-13), n = 51 3.49 (3.77, 0-13), n = 41

DASS anxiety 2.66 (2.97, 0-9), n = 50 2.63 (2.99, 0-11), n = 41

DASS stress 5.60 (3.57, 0-13), n = 50 4.61 (4.41, 0-15), n = 41

Fathers

PSOC satisfaction 3.90 (0.93, 2.17-5.67), n = 29 3.55 (0.78, 2.33-5), n = 20

PSOC efficacy 4.35 (0.93, 3-5.71), n = 29 4.26 (0.80, 2.71-5.57), n = 20

PSOC interest 4.52 (0.95, 2.5-6), n = 29 4.85 (1.05, 2.5-6), n = 20

DASS depression 2.70 (3.68, 0-15), n = 30 5.10 (4.99, 0-16), n = 20

DASS anxiety 2.45 (2.71, 0-11), n = 29 2.35 (3.51, 0-13), n = 20

DASS stress 4.24 (3.77, 0-15), n = 29 5.85 (5.07, 0-15), n = 20

CALD: Culturally and linguistically diverse; PSOC: Parenting Sense of Competence; DASS: DepressionAnxiety Stress Scale.

score is based on education level, however the current study did not differentiatebetween TAFE or other vocational educational or post-secondary education anduniversity bachelor level qualifications. Thus, all who indicated tertiary leveleducation received the same higher AUSEI06 score. This use of educational level toimpute SES may be particularly problematic in the case of parents of children withautism and other developmental disabilities as previous studies have found thatalthough parents tend to have higher education levels, due to the significantchallenges in caring for their children, they may be unemployed or underemployedand may have lower than expected income compared to their full educationalpotential[42,58,94-98]. Further, the AUSEI06’s failure to consider the extent to which aparent participates in the workforce, whether full time or part time, could have alsoinflated parental SES. The majority of studies examining SES have failed to includepersonal and environmental measures of SES and the inclusion of a measure ofcommunity SES is a significant strength of our study. Further exploration of therelationship between ASD symptom severity and parental wellbeing and sense ofparenting competency using alternative measures of SES such as household income istherefore required.

Our study suggests that SES differentially impacts wellbeing and sense ofparenting competence and its relationship to the impact of child symptoms formothers and fathers of preschoolers with autism. Such differences between mothersand fathers need to be further understood to inform targeted parental intervention.Given the integral role of parents in ensuring the success of early interventionprograms[13], it is essential that these interventions address the determinants ofparental wellbeing as well as child-specific outcomes.

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

40

Table 6 Significant correlations between measures of parenting sense of competence and wellbeing and autism spectrum disordersymptom severity for the whole sample and by levels of socioeconomic status

Mothers Fathers

Full sample Sample by AUSEI06 Sample by IRSAD Full sample Sample by AUSEI06 Sample by IRSAD

PSOC satisfaction

Negative: SCQcommunication, r(99) =-0.270, P = 0.007

Top third of SES:Negative: SCQ total,

r(60) = -0.317, P = 0.013

Middle third of SES:Negative: SCQ

communication, r(39) = -0.457, P = 0.003

Negative: SCQ total,r(100) = -0.264, P =0.008

Negative: SCQcommunication, r(59) = -

0.300, P = 0.021

Top third of SES:Negative: SCQ

communication, r(17) = -0.545, P = 0.024

Negative: SCQ social,r(100) =-0.226, = 0.024

Negative: SCQ RRBI,r(17) = -0.553, P = 0.021

Positive: VABS -adaptive, r(90) = 0.235,P = 0.026

Negative: SCQ total,r(17) = -0.572, P = 0.016

PSOC efficacy

Negative: SCQ social,r(100) = -0.291, P =0.003

Top third of SES:Positive: VABS -

adaptive, r(56) = 0.360, P= 0.006

Top third of SES:Negative: SCQ

communication, r(17) = -0.719, P = 0.001

Top third of SES:Negative: VABS -

maladaptive, r(37) = -0.461, P = 0.004

Bottom third of SES:Negative: VABS -

maladaptive, r(23) = -0.487, P = 0.018

Negative: SCQ RRSB,r(100) = -0.307, P =0.002

Negative: SCQ total,r(60) = -0.374, P = 0.003

Negative: SCQ social,r(17) = -0.609, P = 0.010

Negative: SCQ total,r(39) = -0.449, P = 0.004

Negative: SCQ total,r(100) = -0.348, P <0.001

Negative: SCQ Social,r(60) = -0.304, P = 0.018

Negative: SCQ Total,r(17) = -0.660, P = 0.004

Positive: VABS -adaptive, r(90) = 0.230,P = 0.029

Negative: SCQ RRBI,r(60) = -0.312, P = 0.015

PSOC interest

Positive: IRSAD, r(106)= 0.278, P = 0.004

Middle third of SES:Negative: SCQ

communication, r(39) = -0.364, P = 0.023

Top third of SES:Negative: SCQ

communication, r(17) = -0.553, P = 0.021

DASS depression

Negative: VABS -adaptive, r(85) = -0.258,P = 0.017

Top third of SES:Negative: VABS -

adaptive, r(14) = -0.664,P = 0.010

Negative: AUSEI06,r(52) = -0.323, P = 0.020

Positive: SCQ total,r(95) = 0.238, P = 0.020

DASS anxiety

Top third of SES:Positive: VABS -

maladaptive, r(14) =0.644, P = 0.013

Negative: AUSEI06,r(52) = -0.316, P = 0.023

DASS stress

Top third of SES:Positive: ADOS

comparison (severity)score, r(14) = 0.635, P =

0.015

Negative: AUSEI06,r(53) = -0.305, P = 0.026

The value in parenthesis after “r” is the sample size for the analysis (n). PSOC: Parenting Sense of Competence; DASS: Depression Anxiety Stress Scale;SCQ: Social Communication Questionnaire; VABS: Vineland Adaptive Behavior Scales; IRSAD: Index of Relative Socio-economic Advantage andDisadvantage; AUESI06: Australian Socioeconomic Index 2006; SES: Socioeconomic status.

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

41

ARTICLE HIGHLIGHTSResearch backgroundThere is converging evidence that higher levels of stress and psychological distress isexperienced by parents of children with autism compared to typically developing children.

Research motivationThere is limited research on the role of socioeconomic status (SES) on the wellbeing of parents ofpreschool children with autism and its impact if any on parental competency and children'sautism symptom severity

Research objectivesThe primary objective of this study was to examine the relationship between symptom severity,SES and psychological wellbeing among parents of preschoolers with autism. The findings willhave implications for future planning of services to support the parents and also for futureresearch on family and psychosocial predictors of treatment response.

Research methodsThe study assessed parents (mothers and fathers) of preschool-aged children with autism ontheir own perceptions of parental competence and wellbeing using questionnaires and childrenwere assessed using objective standardised measures of autism severity, cognitive level andparent reports of adaptive functioning.

Research resultsA differential impact was observed for mothers and fathers as to the impact of SES and theirchild’s symptom severity on their parenting competence and sense of wellbeing.

Research conclusionsThe findings from this study suggest that SES differentially impacts the wellbeing and sense ofparenting competence in fathers and mothers of preschool children with autism. While bothmothers and fathers displayed higher levels of depression than normative populations, mothersalso reported greater levels of stress and anxiety. Child symptom severity was associated withmaternal parenting competency, and this was exaggerated among mothers with higher familialSES and who lived in areas of greater neighbourhood advantage. However, paternal parentingcompetence was generally not influenced by child adaptive functioning or symptom severity,albeit for those from higher familial SES background, there was an inverse relationship betweenchildren’s symptom severity and maladaptive symptoms and paternal sense of parentingefficacy. This has implications for service provision as it highlights the need for comprehensiveassessment of the support needs for both fathers and mothers independently.

Research perspectivesSince this study was done in a specialised early intervention centre, the findings may have beeninfluenced by sampling bias in terms of access to such services. In this regard, families in thelowest SES category were underrepresented and this was particularly the case for fatherparticipation in this research project. It is possible that lower SES families may not have had thebenefit of early identification and enrolment to early intervention centres such as the one wherethis project was undertaken. This may have been compounded by the fact that fathers fromlower SES background may have less time availability and capacity to participate in research.Future studies would benefit from targeted recruitment of those sections of the autismcommunity who are currently not engaging with routine health services and are alsounderrepresented in research.

ACKNOWLEDGEMENTSThis research was conducted as part of the Child and Family Outcomes Study at theKU Marcia Burgess Autism Specific Early Learning and Care Centre, funded by theAustralian Government with the University of New South Wales as a researchpartner. The authors would like to thank the staff and families who participated in theproject and, in particular, Kate Piromalli, Nicole Lees and Feroza Khan for theirassistance with data collection and Elizabeth Aylward for her support to the researchproject.

REFERENCES1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed.

Washington, DC: American Psychiatric Association, 2013; [DOI: 10.1176/appi.books.9780890425596]2 Elsabbagh M, Divan G, Koh YJ, Kim YS, Kauchali S, Marcín C, Montiel-Nava C, Patel V, Paula CS,

Wang C, Yasamy MT, Fombonne E. Global prevalence of autism and other pervasive developmentaldisorders. Autism Res 2012; 5: 160-179 [PMID: 22495912 DOI: 10.1002/aur.239]

3 Baio J, Wiggins L, Christensen DL, Maenner MJ, Daniels J, Warren Z, Kurzius-Spencer M, ZahorodnyW, Robinson Rosenberg C, White T, Durkin MS, Imm P, Nikolaou L, Yeargin-Allsopp M, Lee LC,

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

42

Harrington R, Lopez M, Fitzgerald RT, Hewitt A, Pettygrove S, Constantino JN, Vehorn A, Shenouda J,Hall-Lande J, Van Naarden Braun K, Dowling NF. Prevalence of Autism Spectrum Disorder AmongChildren Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, UnitedStates, 2014. MMWR Surveill Summ 2018; 67: 1-23 [PMID: 29701730 DOI: 10.15585/mmwr.ss6706a1]

4 Eapen V, Crnčec R, Walter A. Exploring Links between Genotypes, Phenotypes, and Clinical Predictorsof Response to Early Intensive Behavioral Intervention in Autism Spectrum Disorder. Front Hum Neurosci2013; 7: 567 [PMID: 24062668 DOI: 10.3389/fnhum.2013.00567]

5 Altiere MJ, von Kluge S. Searching for acceptance: challenges encountered while raising a child withautism. J Intellect Dev Disabil 2009; 34: 142-152 [PMID: 19404835 DOI: 10.1080/13668250902845202]

6 Whitman TL. The development of autism: A self-regulatory perspective. London: Jessica KingsleyPublishers 2004; Available from: URL:https://www.questia.com/library/119644148/the-development-of-autism-a-self-regulatory-perspective

7 DePape AM, Lindsay S. Parents' experiences of caring for a child with autism spectrum disorder. QualHealth Res 2015; 25: 569-583 [PMID: 25246329 DOI: 10.1177/1049732314552455]

8 Corcoran J, Berry A, Hill S. The lived experience of US parents of children with autism spectrumdisorders: a systematic review and meta-synthesis. J Intellect Disabil 2015; 19: 356-366 [PMID: 25819433DOI: 10.1177/1744629515577876]

9 Bonis S. Stress and Parents of Children with Autism: A Review of Literature. Issues Ment Health Nurs2016; 37: 153-163 [PMID: 27028741 DOI: 10.3109/01612840.2015.1116030]

10 Hayes SA, Watson SL. The impact of parenting stress: a meta-analysis of studies comparing theexperience of parenting stress in parents of children with and without autism spectrum disorder. J AutismDev Disord 2013; 43: 629-642 [PMID: 22790429 DOI: 10.1007/s10803-012-1604-y]

11 Vasilopoulou E, Nisbet J. The quality of life of parents of children with autism spectrum disorder: Asystematic review. Res Autism Spect Dis 2016; 23: 36-49 [DOI: 10.1016/j.rasd.2015.11.008]

12 Karst JS, Van Hecke AV. Parent and family impact of autism spectrum disorders: a review and proposedmodel for intervention evaluation. Clin Child Fam Psychol Rev 2012; 15: 247-277 [PMID: 22869324 DOI:10.1007/s10567-012-0119-6]

13 Osborne LA, McHugh L, Saunders J, Reed P. Parenting stress reduces the effectiveness of early teachinginterventions for autistic spectrum disorders. J Autism Dev Disord 2008; 38: 1092-1103 [PMID: 18027079DOI: 10.1007/s10803-007-0497-7]

14 Hutchison L, Feder M, Abar B, Winsler A. Relations between Parenting Stress, Parenting Style, and ChildExecutive Functioning for Children with ADHD or Autism. J Child Fam Stud 2016; 25: 3644-3656 [DOI:10.1007/s10826-016-0518-2]

15 Arellano A, Denne LD, Hastings RP, Hughes JC. Parenting sense of competence in mothers of childrenwith autism: Associations with parental expectations and levels of family support needs. J Intellect DevDis 2017; 1-7 [DOI: 10.3109/13668250.2017.1350838]

16 Hassall R, Rose J, McDonald J. Parenting stress in mothers of children with an intellectual disability: theeffects of parental cognitions in relation to child characteristics and family support. J Intellect Disabil Res2005; 49: 405-418 [PMID: 15882391 DOI: 10.1111/j.1365-2788.2005.00673.x]

17 Rogers H, Matthews J. The parenting sense of competence scale: Investigation of the factor structure,reliability, and validity for an Australian sample. Aust Psychol 2004; 39: 88-96 [DOI:10.1080/00050060410001660380]

18 Eapen V, Crnčec R, Walter A, Tay KP. Conceptualisation and development of a quality of life measurefor parents of children with autism spectrum disorder. Autism Res Treat 2014; 2014: 160783 [PMID:24778873 DOI: 10.1155/2014/160783]

19 Duarte CS, Bordin IA, Yazigi L, Mooney J. Factors associated with stress in mothers of children withautism. Autism 2005; 9: 416-427 [PMID: 16155057 DOI: 10.1177/1362361305056081]

20 Hastings RP, Johnson E. Stress in UK families conducting intensive home-based behavioral interventionfor their young child with autism. J Autism Dev Disord 2001; 31: 327-336 [PMID: 11518485 DOI:10.1023/a:1010799320795]

21 Hastings RP, Kovshoff H, Ward NJ, degli Espinosa F, Brown T, Remington B. Systems analysis of stressand positive perceptions in mothers and fathers of pre-school children with autism. J Autism Dev Disord2005; 35: 635-644 [PMID: 16177837 DOI: 10.1007/s10803-005-0007-8]

22 Davis NO, Carter AS. Parenting stress in mothers and fathers of toddlers with autism spectrum disorders:associations with child characteristics. J Autism Dev Disord 2008; 38: 1278-1291 [PMID: 18240012 DOI:10.1007/s10803-007-0512-z]

23 Giovagnoli G, Postorino V, Fatta LM, Sanges V, De Peppo L, Vassena L, Rose PD, Vicari S, Mazzone L.Behavioral and emotional profile and parental stress in preschool children with autism spectrum disorder.Res Dev Disabil 2015; 45-46: 411-421 [PMID: 26318505 DOI: 10.1016/j.ridd.2015.08.006]

24 Schutte C, Richardson W, Devlin M, Hill J, Ghossainy M, Hewitson L. The Relationship Between SocialAffect and Restricted and Repetitive Behaviors Measured on the ADOS-2 and Maternal Stress. J AutismDev Disord 2018; 48: 751-758 [PMID: 29322384 DOI: 10.1007/s10803-017-3453-1]

25 Harrop C, McBee M, Boyd BA. How Are Child Restricted and Repetitive Behaviors Associated withCaregiver Stress Over Time? A Parallel Process Multilevel Growth Model. J Autism Dev Disord 2016; 46:1773-1783 [PMID: 26801776 DOI: 10.1007/s10803-016-2707-7]

26 Bishop SL, Richler J, Cain AC, Lord C. Predictors of perceived negative impact in mothers of childrenwith autism spectrum disorder. Am J Ment Retard 2007; 112: 450-461 [PMID: 17963436]

27 Hoppes K, Harris SL. Perceptions of Child Attachment and Maternal Gratification in Mothers of ChildrenWith Autism and Down Syndrome. J Clin Child Psychol 1990; 19: 365-370 [DOI:10.1207/s15374424jccp1904_8]

28 Kasari C, Sigman M. Linking parental perceptions to interactions in young children with autism. J AutismDev Disord 1997; 27: 39-57 [PMID: 9018581 DOI: 10.1023/A:1025869105208]

29 Hattier MA, Matson JL, Belva BC, Horovitz M. The occurrence of challenging behaviours in childrenwith autism spectrum disorders and atypical development. Dev Neurorehabil 2011; 14: 221-229 [PMID:21732806 DOI: 10.3109/17518423.2011.573836]

30 Chiang HM. Expressive communication of children with autism: the use of challenging behaviour. JIntellect Disabil Res 2008; 52: 966-972 [PMID: 18205752 DOI: 10.1111/j.1365-2788.2008.01042.x]

31 Minshawi NF, Hurwitz S, Fodstad JC, Biebl S, Morriss DH, McDougle CJ. The association between self-injurious behaviors and autism spectrum disorders. Psychol Res Behav Manag 2014; 7: 125-136 [PMID:24748827 DOI: 10.2147/PRBM.S44635]

32 Matson JL, Boisjoli J, Mahan S. The relation of communication and challenging behaviors in infants and

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

43

toddlers with autism spectrum disorders. J Dev Phys Disabil 2009; 21: 253-261 [DOI:10.1007/s10882-009-9140-1]

33 Estes A, Munson J, Dawson G, Koehler E, Zhou XH, Abbott R. Parenting stress and psychologicalfunctioning among mothers of preschool children with autism and developmental delay. Autism 2009; 13:375-387 [PMID: 19535467 DOI: 10.1177/1362361309105658]

34 Firth I, Dryer R. The predictors of distress in parents of children with autism spectrum disorder. J IntellectDev Disabil 2013; 38: 163-171 [PMID: 23509963 DOI: 10.3109/13668250.2013.773964]

35 Lecavalier L, Leone S, Wiltz J. The impact of behaviour problems on caregiver stress in young peoplewith autism spectrum disorders. J Intellect Disabil Res 2006; 50: 172-183 [PMID: 16430729 DOI:10.1111/j.1365-2788.2005.00732.x]

36 Zaidman-Zait A, Mirenda P, Duku E, Vaillancourt T, Smith IM, Szatmari P, Bryson S, Fombonne E,Volden J, Waddell C, Zwaigenbaum L, Georgiades S, Bennett T, Elsabaggh M, Thompson A. Impact ofpersonal and social resources on parenting stress in mothers of children with autism spectrum disorder.Autism 2017; 21: 155-166 [PMID: 27091948 DOI: 10.1177/1362361316633033]

37 Falk NH, Norris K, Quinn MG. The factors predicting stress, anxiety and depression in the parents ofchildren with autism. J Autism Dev Disord 2014; 44: 3185-3203 [PMID: 25022253 DOI:10.1007/s10803-014-2189-4]

38 Belsky J. The determinants of parenting: a process model. Child Dev 1984; 55: 83-96 [PMID: 6705636DOI: 10.2307/1129836]

39 Wadsworth ME, Raviv T, Reinhard C, Wolff B, Santiago CD, Einhorn L. An Indirect Effects Model ofthe Association Between Poverty and Child Functioning: The Role of Children's Poverty-Related Stress. JLoss Trauma 2008; 13: 156-185 [DOI: 10.1080/15325020701742185]

40 Stafford M, Marmot M. Neighbourhood deprivation and health: does it affect us all equally? Int JEpidemiol 2003; 32: 357-366 [PMID: 12777420 DOI: 10.1093/ije/dyg084]

41 Montes G, Halterman JS. Psychological functioning and coping among mothers of children with autism: apopulation-based study. Pediatrics 2007; 119: e1040-e1046 [PMID: 17473077 DOI:10.1542/peds.2006-2819]

42 Horlin C, Falkmer M, Parsons R, Albrecht MA, Falkmer T. The cost of autism spectrum disorders. PLoSOne 2014; 9: e106552 [PMID: 25191755 DOI: 10.1371/journal.pone.0106552]

43 Fávero-Nunes MA, dos Santos MA. Depression and quality of life in mothers of children with pervasivedevelopmental disorders. Rev Lat Am Enfermagem 2010; 18: 33-40 [PMID: 20428694 DOI:10.1590/S0104-11692010000100006]

44 Hodgetts S, McConnell D, Zwaigenbaum L, Nicholas D. The impact of autism services on mothers'psychological wellbeing. Child Care Health Dev 2017; 43: 18-30 [PMID: 27620870 DOI:10.1111/cch.12398]

45 Benson PR. The impact of child symptom severity on depressed mood among parents of children withASD: the mediating role of stress proliferation. J Autism Dev Disord 2006; 36: 685-695 [PMID: 16835810DOI: 10.1007/s10803-006-0112-3]

46 Abbeduto L, Seltzer MM, Shattuck P, Krauss MW, Orsmond G, Murphy MM. Psychological well-beingand coping in mothers of youths with autism, Down syndrome, or fragile X syndrome. Am J Ment Retard2004; 109: 237-254 [PMID: 15072518 DOI: 10.1352/0895-8017(2004)109<237:PWACIM>2.0.CO;2]

47 Hoare P, Harris M, Jackson P, Kerley S. A community survey of children with severe intellectualdisability and their families: psychological adjustment, carer distress and the effect of respite care. JIntellect Disabil Res 1998; 42: 218-227 [PMID: 9678406 DOI: 10.1046/j.1365-2788.1998.00134.x]

48 Ahmad MM, Dardas LA. The hidden patients: Fathers of children with autism spectrum disorder. JIntellect Dev Dis 2015; 40: 368-375 [DOI: 10.3109/13668250.2015.1064879]

49 Pickard KE, Ingersoll BR. Quality versus quantity: The role of socioeconomic status on parent-reportedservice knowledge, service use, unmet service needs, and barriers to service use. Autism 2016; 20: 106-115[PMID: 25948601 DOI: 10.1177/1362361315569745]

50 Mayes SD, Calhoun SL. Impact of IQ, age, SES, gender, and race on autistic symptoms. Res Autism SpectDis 2011; 5: 749-757 [DOI: 10.1016/j.rasd.2010.09.002]

51 Mayes SD, Calhoun SL, Aggarwal R, Baker C, Mathapati S, Anderson R, Petersen C. Explosive,oppositional, and aggressive behavior in children with autism compared to other clinical disorders andtypical children. Res Autism Spect Dis 2012; 6: 1-10 [DOI: 10.1016/j.rasd.2011.08.001]

52 Delobel-Ayoub M, Ehlinger V, Klapouszczak D, Maffre T, Raynaud JP, Delpierre C, Arnaud C.Socioeconomic Disparities and Prevalence of Autism Spectrum Disorders and Intellectual Disability. PLoSOne 2015; 10: e0141964 [PMID: 26540408 DOI: 10.1371/journal.pone.0141964]

53 Durkin MS, Maenner MJ, Baio J, Christensen D, Daniels J, Fitzgerald R, Imm P, Lee LC, Schieve LA,Van Naarden Braun K, Wingate MS, Yeargin-Allsopp M. Autism Spectrum Disorder Among US Children(2002-2010): Socioeconomic, Racial, and Ethnic Disparities. Am J Public Health 2017; 107: 1818-1826[PMID: 28933930 DOI: 10.2105/AJPH.2017.304032]

54 Daniels AM, Mandell DS. Explaining differences in age at autism spectrum disorder diagnosis: a criticalreview. Autism 2014; 18: 583-597 [PMID: 23787411 DOI: 10.1177/1362361313480277]

55 Mandell DS, Wiggins LD, Carpenter LA, Daniels J, DiGuiseppi C, Durkin MS, Giarelli E, Morrier MJ,Nicholas JS, Pinto-Martin JA, Shattuck PT, Thomas KC, Yeargin-Allsopp M, Kirby RS. Racial/ethnicdisparities in the identification of children with autism spectrum disorders. Am J Public Health 2009; 99:493-498 [PMID: 19106426 DOI: 10.2105/AJPH.2007.131243]

56 Li X, Sjöstedt C, Sundquist K, Zöller B, Sundquist J. Neighborhood deprivation and childhood autism: anationwide study from Sweden. J Psychiatr Res 2014; 53: 187-192 [PMID: 24613033 DOI:10.1016/j.jpsychires.2014.02.011]

57 Wing L. Childhood autism and social class: a question of selection? Br J Psychiatry 1980; 137: 410-417[PMID: 7470767 DOI: 10.1192/bjp.137.5.410]

58 Dardas LA, Ahmad MM. Predictors of quality of life for fathers and mothers of children with autisticdisorder. Res Dev Disabil 2014; 35: 1326-1333 [PMID: 24704547 DOI: 10.1016/j.ridd.2014.03.009]

59 Rogers SJ, Dawson G. Early start Denver model for young children with autism: Promoting language,learning, and engagement. Guilford Press, 2010. Available from: URL:https://eric.ed.gov/?q=manualsid=ED510199

60 Dawson G, Rogers S, Munson J, Smith M, Winter J, Greenson J, Donaldson A, Varley J. Randomized,controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics 2010;125: e17-e23 [PMID: 19948568 DOI: 10.1542/peds.2009-0958]

61 Eapen V, Crnčec R, Walter A. Clinical outcomes of an early intervention program for preschool children

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

44

with Autism Spectrum Disorder in a community group setting. BMC Pediatr 2013; 13: 3 [PMID:23294523 DOI: 10.1186/1471-2431-13-3]

62 Johnston C, Mash EJ. A Measure of Parenting Satisfaction and Efficacy. J Clin Child Psychol 1989; 18:167-175 [DOI: 10.1207/s15374424jccp1802_8]

63 Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney:Psychology Foundation of Australia 1995; Available from: URL: https://trove.nla.gov.au/work/30421447

64 Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. PsycholAssess 1998; 10: 176 [DOI: 10.1037/1040-3590.10.2.176]

65 Henry JD, Crawford JR. The short-form version of the Depression Anxiety Stress Scales (DASS-21):construct validity and normative data in a large non-clinical sample. Br J Clin Psychol 2005; 44: 227-239[PMID: 16004657 DOI: 10.1348/014466505X29657]

66 Rutter M, Bailey A, Lord C. Social Communication Questionnaire (SCQ). Los Angeles: WesternPsychological Services 2003; Available from: URL: https://www.carautismroadmap.org/social-commu-nication-questionnaire-scq/

67 Lord C, Rutter M, DiLavore PC, Risi S, Gotham K, Bishop SL. Autism diagnostic observation schedule(ADOS): Manual. Western Psychological Services, 2000. Available from: URL:https://www.wpspublish.com/store/p/2647/ados-autism-diagnostic-observation-schedule

68 Lord C, Rutter M, DiLavore PC, Risi S, Gotham K, Bishop SL. (ADOS™-2) Autism DiagnosticObservation Schedule™, Second Edition. Los Angeles: Western Psychological Services 2012; Availablefrom: URL:https://www.wpspublish.com/store/p/2648/ados-2-autism-diagnostic-observation-schedule-second-edition

69 Chandler S, Charman T, Baird G, Simonoff E, Loucas T, Meldrum D, Scott M, Pickles A. Validation ofthe social communication questionnaire in a population cohort of children with autism spectrum disorders.J Am Acad Child Adolesc Psychiatry 2007; 46: 1324-1332 [PMID: 17885574]

70 Skuse DH, Mandy WP, Scourfield J. Measuring autistic traits: heritability, reliability and validity of theSocial and Communication Disorders Checklist. Br J Psychiatry 2005; 187: 568-572 [PMID: 16319410DOI: 10.1192/bjp.187.6.568]

71 Snow AV, Lecavalier L. Sensitivity and specificity of the Modified Checklist for Autism in Toddlers andthe Social Communication Questionnaire in preschoolers suspected of having pervasive developmentaldisorders. Autism 2008; 12: 627-644 [PMID: 19005032 DOI: 10.1177/1362361308097116]

72 Sparrow S, Cicchetti D, Balla D. Vineland Adaptive Behavior Scales (2nd ed.). Minneapolis, MN:Pearson Assessment 2005; Available from: URL:https://www.pearsonclinical.com/psychology/products/100000668/vineland-adaptive-behavior-scales-second-edition-vineland-ii-vineland-ii.html

73 McMillan J, Jones L, Beavis A. A new scale for measuring socioeconomic status in educational research:development and validation of the Australian Socioeconomic Index 2006 (AUSEI06). Paper presented atthe 2009 AARE International Education Research Conference, Canberra: National Convention Centre2009; Available from: URL: https://www.aare.edu.au/data/publications/2009/mcm091513.pdf

74 Australian Bureau of Statistics and Statistics New Zealand. 1220.0 - ANZSCO - Australian and NewZealand Standard Classification of Occupations, First Edition. Australian Bureau of Statistics: Canberra2006; Available from: URL:http://www.abs.gov.au/ausstats/abs@.nsf/Product+Lookup/1220.0~2006~Chapter~UNIT+GROUP+3212+Motor+Mechanics

75 Ganzeboom HB, De Graaf PM, Treiman DJ. A standard international socio-economic index ofoccupational status. Soc Sci Res 1992; 21: 1-56 [DOI: 10.1016/0049-089X(92)90017-B]

76 Australian Bureau of Statistics. 2033.0.55.001 - Census of Population and Housing: Socio-EconomicIndexes for Areas (SEIFA). Canberra, Australia, 2016. Available from: URL: https://www.abs.gov.au/aus-stats/abs@.nsf/mf/2033.0.55.001

77 Australian Bureau of Statistics. Technical Paper: Socio-Economic Indexes for Areas (SEIFA). Canberra,Australia, 2016. Available from: URL:http://www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/756EE3DBEFA869EFCA258259000BA746/$File/SEIFA%202016%20Technical%20Paper.pdf

78 Crawford J, Cayley C, Lovibond Peter F, Wilson Peter H, Hartley C. Percentile Norms andAccompanying Interval Estimates from an Australian General Adult Population Sample for Self-ReportMood Scales (BAI, BDI, CRSD, CES-D, DASS, DASS-21, STAI-X, STAI-Y, SRDS, and SRAS). AustPsychol 2011; 46: 3-14 [DOI: 10.1111/j.1742-9544.2010.00003.x]

79 Cohen J. Statistical Power Analysis for the Behavioral Sciences. New York: L. Erlbaum Associates 1988;Available from: URL: http://www.utstat.toronto.edu/~brunner/oldclass/378f16/readings/CohenPower.pdf

80 Braunstein VL, Peniston N, Perelman A, Cassano MC. The inclusion of fathers in investigations ofautistic spectrum disorders. Res Autism Spect Dis 2013; 7: 858-865 [DOI: 10.1016/j.rasd.2013.03.005]

81 Paynter J, Davies M, Beamish W. Recognising the "forgotten man": Fathers' experiences in caring for ayoung child with autism spectrum disorder. J Intellect Dev Dis 2018; 43: 112-124 [DOI:10.3109/13668250.2017.1293235]

82 Totsika V, Hastings RP, Emerson E, Lancaster GA, Berridge DM, Vagenas D. Is there a bidirectionalrelationship between maternal well-being and child behavior problems in autism spectrum disorders?Longitudinal analysis of a population-defined sample of young children. Autism Res 2013; 6: 201-211[PMID: 23436803 DOI: 10.1002/aur.1279]

83 Ohan JL, Leung DW, Johnston C. The Parenting Sense of Competence scale: Evidence of a stable factorstructure and validity. Can J Behav Sci 2000; 32: 251-261 [DOI: 10.1037/h0087122]

84 Davis-Kean PE. The influence of parent education and family income on child achievement: the indirectrole of parental expectations and the home environment. J Fam Psychol 2005; 19: 294-304 [PMID:15982107 DOI: 10.1037/0893-3200.19.2.294]

85 Singer GH. Meta-analysis of comparative studies of depression in mothers of children with and withoutdevelopmental disabilities. Am J Ment Retard 2006; 111: 155-169 [PMID: 16597183]

86 Bitsika V, Sharpley CF. Stress, Anxiety and Depression Among Parents of Children With AutismSpectrum Disorder. Aust J Guid Couns 2004; 14: 151-161 [DOI: 10.1017/S1037291100002466]

87 Baker-Ericzén MJ, Brookman-Frazee L, Stahmer A. Stress levels and adaptability in parents of toddlerswith and without autism spectrum disorders. Res Pract Pers Sev D 2005; 30: 194-204 [DOI:10.2511/rpsd.30.4.194]

88 Olsson MB, Hwang CP. Depression in mothers and fathers of children with intellectual disability. J

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

45

Intellect Disabil Res 2001; 45: 535-543 [PMID: 11737541 DOI: 10.1046/j.1365-2788.2001.00372.x]89 Dabrowska A, Pisula E. Parenting stress and coping styles in mothers and fathers of pre-school children

with autism and Down syndrome. J Intellect Disabil Res 2010; 54: 266-280 [PMID: 20146741 DOI:10.1111/j.1365-2788.2010.01258.x]

90 Giallo R, Wood CE, Jellett R, Porter R. Fatigue, wellbeing and parental self-efficacy in mothers ofchildren with an autism spectrum disorder. Autism 2013; 17: 465-480 [PMID: 21788255 DOI:10.1177/1362361311416830]

91 Jiang Y, Gurm M, Johnston C. Child impairment and parenting self-efficacy in relation to mothers' viewsof ADHD treatments. J Atten Disord 2014; 18: 532-541 [PMID: 22628141 DOI:10.1177/1087054712443412]

92 Bhasin TK, Schendel D. Sociodemographic risk factors for autism in a US metropolitan area. J AutismDev Disord 2007; 37: 667-677 [PMID: 16951989 DOI: 10.1007/s10803-006-0194-y]

93 Bilder D, Pinborough-Zimmerman J, Miller J, McMahon W. Prenatal, perinatal, and neonatal factorsassociated with autism spectrum disorders. Pediatrics 2009; 123: 1293-1300 [PMID: 19403494 DOI:10.1542/peds.2008-0927]

94 Croen LA, Grether JK, Selvin S. Descriptive epidemiology of autism in a California population: who is atrisk? J Autism Dev Disord 2002; 32: 217-224 [PMID: 12108623 DOI: 10.1023/a:1015405914950]

95 Bourke-Taylor H, Howie L, Law M. Barriers to maternal workforce participation and relationshipbetween paid work and health. J Intellect Disabil Res 2011; 55: 511-520 [PMID: 21385261 DOI:10.1111/j.1365-2788.2011.01407.x]

96 Leiter V, Krauss MW, Anderson B, Wells N. The Consequences of Caring: Effects of Mothering a Childwith Special Needs. J Fam Issues 2004; 25: 379-403 [DOI: 10.1177/0192513X03257415]

97 Parish SL, Seltzer MM, Greenberg JS, Floyd F. Economic implications of caregiving at midlife:comparing parents with and without children who have developmental disabilities. Ment Retard 2004; 42:413-426 [PMID: 15516174 DOI: 10.1352/0047-6765(2004)42<413:EIOCAM>2.0.CO;2]

98 Warfield ME. Family and work predictors of parenting role stress among twoearner families of childrenwith disabilities. Infant Child Dev 2005; 14: 155-176 [DOI: 10.1002/icd.386]

P- Reviewer: Caponneto P, Gordon JS- Editor: Ji FF L- Editor: A E- Editor: Bian YN

WJP https://www.wjgnet.com March 27, 2019 Volume 9 Issue 2

Mathew NE et al. SES and parenting preschoolers with ASD

46

Published By Baishideng Publishing Group Inc

7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Telephone: +1-925-2238242

Fax: +1-925-2238243

E-mail: bpgoffice@wjgnet.com

Help Desk:https://www.f6publishing.com/helpdesk

https://www.wjgnet.com

© 2019 Baishideng Publishing Group Inc. All rights reserved.